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Salary Continuation Agreement BWC-1174 - Ohio

Salary Continuation Agreement Form. This is a Ohio form and can be used in Employers Workers Comp .
 Fillable pdf Last Modified 2/25/2015
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Salary Continuation Agreement This form can be obtained online at: www.bwc.ohio.gov Instructions · · · · This form is used to acknowledge an agreement to pay salary/wage continuation in lieu of temporary total or living maintenance compensation. Regular (full) salary/wages includes any benefits which the employee would normally be entitled to if the employee was working. This form must be signed by the employee and the employer. Fax or mail this completed agreement to your local BWC service office. Claim number Policy number Employer telephone number Employee name Employer name On the ________ day of _________________ , ______ , ____________________________ , the employer and Employer name the employee named above executed the following terms and conditions pertaining to the payment of salary continuation. The employer, since the inception of the employee's disability resulting from an accident/occupational disease suffered by the employee on ____ / ____ / ____ , while in course of their employment, has been or is paying regular (full) salary/wages in lieu of temporary total or living maintenance compensation, to the employee during the period of disability as indicated below: Continuation of regular (full) salary/wages and any benefits the injured worker would otherwise have been entitled to has been/ will be paid. Salary continuation will be paid at the rate of $ ________________ per ________________(week, two weeks, etc.) for the period of time from ____ / ____ / ____ to ____ / ____ / ____, (a period of time not to exceed 45 days per C-55 submission). Does the amount paid include salary/wages from other employment? Yes No Should salary continuation payment continue a new C-55 must be submitted within five days of the end date of this agreement. The employer must notify BWC immediately if salary continuation will be discontinued and/or if the injured worker returns to work. Employee signature Employer signature and title Date Date BWC-1174 American LegalNet, Inc. www.FormsWorkFlow.com C-55
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